Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 1783 | WI |
NPI | 1619058526 |
---|---|
Provider Name | Robert A Servais JR. |
First Address | Green Bay, WI 54311-5605 |
Second Address | Green Bay, WI 54311-5605 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2006 |
Last Update Date | 08/07/2007 |